Onset of erythema multiforme-like lesions in association with recurrence of symptoms of COVID-19 infection in an elderly woman.

Dear Editor,

We read with great interest the manuscript recently reported by Askin et al. The authors describe different patterns of cutaneous manifestations in 52 patients during Coronavirus Disease 19 (COVID‐19), including erythematous scaly rash, maculopapular rash, urticarial lesions, petechial purpuric rash, necrosis, enanthema and apthous stomatitis, vesicular rash, pernio, and pruritus. These clinical patterns are in concordance with previous reported studies. , , In addition to these cutaneous manifestations, we would like to emphasize that a few cases of erythema multiforme (EM) like rashes related to COVID‐19 have recently been reported. , , , , , These cases have mainly been observed in young patients and have been associated with milder COVID‐19 disease course. We present herein a new case of EM‐like lesions in an elderly patient with recurrence of symptoms of COVID‐19 infection.

A 95‐year‐old woman was admitted to the hospital with a slightly itchy cutaneous rash, fever, and dyspnea during the COVID‐19 outbreak in Spain. She had been discharged 2 days before, once recovered from COVID‐19 pneumonia (CURB‐65 2p) and after completing a 10‐day course of hydroxychloroquine. Physical examination revealed typical target and targetoid lesions on the trunk and extremities, and confluent purpuric macules on the lower limbs (Figure 1a,b). Mucous membranes were spared. A chest radiograph showed patches of increased density in both hemithorax with a peripheral predominance. The findings had minimally worsened respect to the chest X‐ray performed before discharge. Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was isolated from a sputum culture. Blood count showed mild leukocytosis with neutrophilia and large granular lymphocytes were seen in a blood smear. Serological study on parvovirus B19 infection showed negative IgM and positive IgG. A skin biopsy was obtained from a representative lesion of the thigh. A superficial perivascular and interstitial dermatitis with a predominantly mononuclear inflammatory infiltrate was observed. Symptomatic treatment for fever and dyspnea and topical corticosteroids were initiated with progressive improvement of the skin lesions.

FIGURE 1

A, Targetoid and typical target lesions on upper extremities. B, target lesions on lower limbs and confluent violaceous macules on the back of the knees

EM‐like eruptions related to COVID‐19 infection have rarely been described. To our knowledge, <20 cases have been previously reported in the medical literature. Comparing our case with those described previously, we consider it relevant to highlight the following findings: (a) this is the first case in which respiratory symptoms of COVID‐19 infection and EM‐like rash developed simultaneously. (b) The age of our patient is distinctive given the age range of the patients previously reported, which ranges from 11to 17 years in children , and from 29 to 77 years in adults. , , , In this case, we cannot completely rule out that hydroxychloroquine could be implicated in the development of EM‐like rash. However, there are some clues that suggest an infectious cause rather than a toxicoderma. Thus, the coexistence of fever, respiratory symptoms, and radiologic worsening are not typical findings in a drug reaction. Moreover, no eosinophils were observed in the histopathological examination of the skin lesions. Finally, and in accordance with previous reports, it should be noted that our patient had an excellent outcome, although a fatal case of COVID‐19 infection with EM‐like eruption has been recently described.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS

Leandra Reguero‐Del Cura: Acquisition of data. Writing the manuscript. Cristina Gómez‐Fernández: Revising the manuscript critically. Approval of the version of the manuscript to be published. Cristina López Obregón and Ana Elisabet López‐Sundh: Acquisition of data. Marcos Antonio González‐López: Revising the manuscript critically. Approval of the version of the manuscript to be published. Election of the journal.